Individual at Bedford

Investigation into the circumstances surrounding the
death of a man at HMP Bedford on 1 May 2006
Report by the Prisons and Probation Ombudsman for
England and Wales
November 2007
This is the report of an investigation into the death of a man on 1 May 2006
while in the custody of HMP Bedford. The 43 year old man was suffering from
depression and was located in the healthcare centre for closer supervision. It
was there that he took his own life, using a bed sheet attached to a window.
The man was transferred to a local hospital, where he died at three minutes
past midnight on 1 May 2006.
This version of my report, published on my website, has been amended to
remove the name of the man who died and those of the staff and prisoners
involved in my investigation.
I must express my sincere condolences to the man’s family, who shared in his
happiness and supported him through his more desperate times. I know that
his death has caused much grief. I only hope that this report goes some way
to answering the questions they have surrounding his death.
I appointed two of my fatal incidents investigators to carry out this
investigation on my behalf. Bedfordshire Primary Care Trust appointed a
clinical reviewer to complete an independent clinical review into the man’s
medical care during his time at Bedford. I would like to thank the clinical
reviewer for his comprehensive review. In addition, I would like to thank the
pharmacy technician who reviewed the man’s medication and made two
recommendations in an additional report, attached to the clinical review.
This report focuses on the approach to the man’s detoxification from alcohol
and upon the regime in Bedford’s healthcare centre. He was in prison for just
over two months. He had no previous experience of custody.
I make nine recommendations in addition to the eight made by the clinical
review team.
Stephen Shaw CBE
Prisons and Probation Ombudsman November 2007
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CONTENTS
Summary 4
The Investigation Process 6
HMP Bedford 7
Key Events 8
Issues 22
Recommendations 31
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SUMMARY
The man was struggling with alcoholism and depression when he was
arrested and remanded into the custody of HMP Woodhill on 25 February
2006. He remained at Woodhill for only six days. On 3 March, following a
court appearance, he was remanded to the custody of HMP Bedford.
At Woodhill, the man was felt to be at risk of self-harm or suicide and was
placed on the special support and monitoring arrangements known as ACCT
(Assessment, Care in Custody and Teamwork). He continued to be subject to
ACCT procedures for a short time after his transfer to Bedford. He also
underwent a detoxification process for two weeks and received medication for
his depression.
At Bedford, he seemed to settle on the wing and got on well with staff and
prisoners. In consultation with the man, staff agreed that his ACCT file could
be closed in mid-March because the risk of self-harm had reduced. On 8
April, the ACCT was reopened after he self-harmed. He was also made
subject to an hourly special watch.
The man obtained the sought-after job of Stores Orderly which afforded him
much time out of his cell in the fresh air. Unfortunately, due to his depression
he found it harder and harder to get out of bed in the morning. Staff were
concerned about him and, in line with Bedford’s suicide prevention strategy,
transferred him to the healthcare centre. The ratio of staff to prisoners is
higher in the healthcare centre and it was hoped that he might receive an
enhanced level of care.
The man was in the healthcare centre for the last nine days of his life. He
shared a dormitory cell for the majority of those nine days. The limited regime
meant that he spent most of his day alone with another prisoner whose also
exhibited self-harming behaviour, and I have little doubt that this will have
affected his already depressed mental state.
The man asked to be moved to another cell in the healthcare centre (there is
only one dormitory cell in the healthcare centre and the rest are single cells).
On the evening of 30 April, he was moved to a single cell. His observation
levels were not increased and no note was written by the member of staff who
authorised the transfer.
The nurse and the healthcare assistant on duty that night started their shift on
30 April at 8.30pm. The healthcare assistant noticed that the man seemed
much more down than usual and spoke to him for a considerable length of
time about his problems. Together, they planned the steps that he could take
to improve his situation. Following this conversation, the healthcare assistant,
in agreement with the nurse, increased the man’s observation levels to half-
hourly. However, within an hour the man was discovered hanging in his
single cell at 11.05pm.
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Resuscitation efforts were started by prison officers who were helped by the
nurse. An ambulance was called and the man was taken to the local hospital,
where he was pronounced dead at three minutes past midnight on 1 May
2006.
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THE INVESTIGATION PROCESS
1. I appointed two colleagues to conduct the investigation into the man’s
death on my behalf. On 8 May 2006, the investigation team went to
Bedford to gather his prison records. They met with the governing
Governor, with union representatives and with a member of the
prison’s Independent Monitoring Board. They were briefed about the
prison and its staff.
2. The investigation team issued notices of their investigation and invited
staff and prisoners to contact them with any information that they felt
might be relevant to the investigation. One prisoner contacted my
office and he was interviewed.
3. The investigation team attended the prison in May and June to
interview staff and prisoners. On 6 June, one of the investigators and
one of my family liaison officers met the man’s family to give them an
opportunity to voice their concerns. These have been considered in
the investigation and are explored in further detail in this report. During
the meeting, the family requested copies of the man’s prison records
which they were sent in July 2006.
4. Bedfordshire Primary Care Trust (PCT) expressed concern about
conducting the clinical review into the man’s death. From April 2004,
Bedfordshire PCT has delivered healthcare services in HMP Bedford,
and the PCT was worried that they would not be in a position to review
the quality of clinical care delivered by their colleagues with sufficient
independence. With this in mind, the PCT sought to appoint an
independent clinical reviewer from a neighbouring county. After some
delay, the head of healthcare at in a neighbouring PCT was appointed
as clinical reviewer. One of my investigators met with the clinical
reviewer on 5 July to outline the preliminary findings and discuss the
direction of his clinical review. I would like to thank the clinical reviewer
for his excellent clinical review, which has made a substantial
contribution to the effectiveness of this investigation.
5. In November 2006, the man’s family was asked whether any additional
concerns had been raised by the prison documentation they had been
sent. A number of additional issues have been explored.
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HMP BEDFORD
6. HMP Bedford is a medium-size local prison, most of which was
constructed in the nineteenth century. Although it has a couple of
modern extensions, further expansion of the prison’s facilities is made
difficult by its location in the centre of the town. As a local prison,
Bedford serves a number of courts in the area. There are
comparatively few sentenced prisoners. With a large number of
prisoners being remanded directly from court, there are significant
demands on the detoxification programme. The large numbers of
remand prisoners mean that the population is ever-changing.
7. Her Majesty’s Chief Inspector of Prisons last made a full announced
inspection of Bedford in January 2004. A follow-up unannounced
inspection took place in April 2006, just over two weeks before the
man, who is the subject of this investigation report, died. In her
reports, the Chief Inspector recognises the challenges faced by busy
local prisons such as Bedford. It is within this context that she
acknowledges that Bedford “has begun to travel towards becoming a
healthy local prison”.
8. In January 2004, the Chief Inspector recommended that “in-patients
should be provided with a therapeutic regime”. During the follow-up
inspection, the inspection team found that this recommendation had
still not been achieved and noted:
“Prisoners on the in-patient unit told us that they had very little time out
of cell. Their cells did not have electricity, so they were unable to
watch television in them. When they were unlocked there was no
structured therapeutic regime. They were sometimes offered exercise,
but not every day, and there was little for them to do.”
9. Since I became responsible for the investigation of deaths in prisons in
April 2004, there have been three other apparently self-inflicted deaths
at Bedford. I have considered these investigations during the course of
completing this report. In particular, I am pleased to note that,
following the death of the man who is the subject of this investigation,
the support available to staff was much improved in accordance with a
previous recommendation.
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KEY EVENTS
10. The man was taken into police custody on 24 February 2006. While at
a local police station, he attempted to cut his left forearm in an act of
deliberate self-harm. The next day, he appeared at a Magistrates’
Court and was remanded to HMP Woodhill in Milton Keynes. He was
facing a charge of assault causing actual bodily harm. This was his
first time in custody.
11. Upon arrival at a prison for the first time, all prisoners must have a First
Reception Health Screening. This is an interview with a member of
healthcare staff to discuss any medical issues that need to be
addressed. The prisoner is also risk-assessed to identify how likely
they are to self-harm or attempt suicide. If the prisoner is thought to be
at risk of self-harm, an ACCT file is opened so that staff can effectively
monitor and record how the prisoner is feeling, and offer appropriate
support.
12. The man underwent his First Reception Health Screen on 25 February
at Woodhill. He was recorded as suffering from depression and
seeking referral for a medical appointment. In the substance use
section of the form, the man admitted that he drank ten to twelve pints
per day and two bottles of wine. The man told the interviewer that he
did not feel like harming himself. An ACCT file was not opened at that
time. The man was referred to the detoxification unit and to a doctor in
connection with his physical and mental health.
13. Just two days after the First Reception Health Screening, a medical
officer at Woodhill, raised a Concern and Keep Safe form. Any
member of staff can raise such a form. The Concern and Keep Safe
form is the first stage of the suicide prevention strategy known as
Assessment and Care in Custody and Teamwork (ACCT). The
medical officer listed six factors for placing the man on an ACCT: his
withdrawal from alcohol, personal problems, treatment for depression,
reported suicidal feelings, the man’s own request and because he had
been observed crying.
14. On the same day (28 February), the man was admitted to the
healthcare centre because he was “expressing ideas of self harm and
suicide”. He was interviewed at 3.00pm in accordance with the ACCT
procedure. The interview assesses the level of risk that an individual
poses to himself, and if there are any factors that would help to reduce
that risk. He told staff that he was feeling low for numerous reasons:
namely his alcohol dependency, difficulties in his personal life and
being remanded into custody. He had attempted suicide at home in
2005 and subsequently spent ten weeks in a psychiatric unit to treat his
depression. He told staff that he wanted to sort his life out and that he
saw a “light at the end of the tunnel”. His ‘Coping Resources’ were
listed as his many friends, his boat, and finding an adult son that he
had never met. The man was put on a low observation level: three
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observations during a day shift and five observations at night.
(Observations require that staff try to talk with the prisoner and gain an
impression of their mood. This would not apply if the prisoner was
asleep.)
15. A telephone call that the man made to his father at 4.30pm on 28
February was cut off half way through due to difficulties with the
telephone line. He told staff that he would try again in the morning.
16. The man rang his cell bell at 6.40pm that evening. He had made cuts
to both forearms. Although the wounds were bleeding, they were not
severe enough to require dressing. The man agreed that he would ring
the cell bell if he self-harmed again. He was offered the opportunity to
call the Samaritans but declined.
17. At just after 10.00pm that evening, the man tried to suffocate himself
with a black plastic bin liner in his cell. He rang the cell bell as agreed.
A staff nurse on duty that evening convinced the man to hand over the
black bag and shoelace that he was using. He was relocated to
another cell in the healthcare centre. He asked to see a Listener. (A
Listener is a prisoner who has been trained by the Samaritans to help
other prisoners who are struggling to cope. They listen to a prisoner’s
problems in confidence and can stay with a prisoner for any length of
time.) The Listener stayed with the man for two hours that night. The
next day, staff observed that he appeared to be a little brighter. He had
also spoken to his father again on the telephone.
18. On 3 March 2006, the man appeared at another Magistrates’ Court.
His case was committed to the Crown Court. On his way to court, he
asked staff to ring his parents to let them know that he would not be
able to attend the visit they had arranged because of his court
appearance. My investigators met with the man’s family during the
course of the investigation. They expressed concern and frustration
about the last minute cancellation of visits so early on in his remand
period.
19. The man was remanded to Bedford prison following this court
appearance. He went through another General Health Screen which
identified the same issues as that completed at Woodhill. When asked
about his acts of self-harm, the man said that he had no further
thoughts of harming himself. He said that he had self-harmed for
domestic reasons which had been addressed in the meantime.
20. The ACCT documentation was transferred to Bedford with him and he
continued to be monitored by staff. By this time, the man’s
observations level was hourly. While he was on the first night centre,
he was recorded as being “in good spirits” and getting on well with his
cell mate. A senior officer completed a case review and CAREMAP.
The man told staff at Bedford that he was sleeping and eating well. He
said he did not feel like self-harming. On the CAREMAP, the senior
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officer recorded only one issue: “feelings of isolation”. To reduce the
risk, the senior officer suggested that the man should share a cell with
someone else. The man also recommended that he contact his family.
21. The man was moved to C wing on 6 March and again recorded as
mixing well with other prisoners. He told an officer on the wing that his
depression was particularly bad in the mornings. On 7 March, the man
was still in bed at 10.35 am, two and a half hours after being woken for
breakfast. He told the same officer on the wing that he was “fine”.
22. The man was escorted to the Magistrates’ Court again on 9 March.
Hourly observations were made by staff who escorted him and at the
court. He was again remanded to Bedford and returned to C wing.
23. An ACCT review took place on 9 March to assess whether the man’s
risk of self-harm had changed. The man told the two officers who
attended the meeting that he felt “more settled” and that he got on with
his cellmate. He was particularly looking forward to his parents visiting
him at the weekend. The man was still considered to be a low level of
risk, but hourly observations continued.
24. On 13 March, the man complained that he felt low in mood. He did not
feel up to collecting his medication and refused exercise. Over the few
days prior to this, he had repeatedly told staff that he was having
difficulty sleeping because he was sharing a cell with someone who
was going through a detoxification programme. At this time, the man
was frequently recorded sleeping well into the afternoon. Another
officer on the wing spoke to the man for about 40 minutes about his
depression. The officer offered him the chance to speak to a Listener
or to the Samaritans, but the man said that he would prefer to talk
things through with the officer. When the conversation ended, he
thanked the officer, who then made a clear entry in the man’s ongoing
self-harm monitoring record.
25. The man was due to take a basic skills test on 14 March. (Prisoners
take this test so that staff can determine what kind of job will best suit
them.) When he was unlocked for the test, the man told the officer that
he did not feel up to taking it as he was depressed. The officer referred
the man to a Community Psychiatric Nurse (CPN).
26. The man refused to leave his cell even to collect his medication. The
doctor visited him at 3.00pm that afternoon. He recorded that the man
was still low in mood and changed the medication to “something
stronger”.
27. The next day, the man kept his appointment with the prison’s CARATs
team. (CARATs is a national programme that supports prisoners who
have substance misuse problems; it stands for Counselling,
Assessment, Referral, Advice and Throughcare.) The man admitted to
drinking ten to twelve pints a day and up to two bottles of wine. In
10
clinical terms, he was an alcoholic. The CARATs team told my
investigators that resources to support alcoholics are limited. As an
identified alcoholic, the team at Bedford met with him and suggested
that he attend an Alcoholics Anonymous group for support. He was
referred to the AA group on 15 March. During his meeting with the
CARATs worker, the man asked to be transferred to D wing. Prisoners
located on D wing are subject to Voluntary Drug Testing and it is
expected that the wing is drug-free.
28. The man’s ACCT document was closed on 17 March. He attended the
review with two members of discipline staff and two CPNs. He was
recorded as being “very settled”. It was noted that he had been placed
on the waiting list for relaxation classes. Otherwise, the record of the
case review determined that “there were no further issues or
problems”. According to his records, the man only attended Alcoholics
Anonymous on one occasion (28 March).
29. In the early hours of 8 April, the man cut his right wrist with a razor
blade. He was sharing a cell with another prisoner at that time. The
cellmate told my investigators that they would often sit up together
throughout the night. He said that the man was particularly worried
about the outcome of his offence. He said that they got on well and it
seemed that the man often felt better after talking things through. The
cellmate remembered waking up to discover that the man had cut
himself. He immediately called for assistance. At that time, it was his
impression that the man was not trying to take his own life. The
cellmate remembered that the man was embarrassed about having cut
himself.
30. An orderly officer responds to any calls for assistance from staff during
the shift. The senior officer who did the man’s original ACCT
CAREMAP was the orderly officer in charge of the prison that night.
The senior officer remembered being called to D wing during his shift.
When he got there, he took the man to the wing office and spoke to
him about why he had harmed himself. Healthcare staff attended and
used a large bandage to dress the cut. The senior officer said that the
wound was superficial, but the large bandage was used because that
was all that was available at the time. The man was concerned about
the effect that seeing such a large bandage would have on his family
who were scheduled to visit the next day. The senior officer advised
him that, if he wanted to stop his family from worrying, all he had to do
was wear a long-sleeved shirt. During the investigation, the man’s wife
expressed concern at the advice that the senior officer gave following
this episode of self-harm. The senior officer assured my investigator
that he thought he was acting in the man’s best interests to reduce his
anxiety during this crisis period.
31. The man told an officer on the wing that he cut his wrist, “as a way of
relieving his frustration at not being able to sleep and the waiting for his
trial”. That officer assessed the man’s level of risk to suicide and self-
11
harm and opened an ACCT document that instructed staff to observe
the him regularly during the night. Another review was arranged for 11
April.
32. As previously arranged, the man’s parents visited him on 8 April. His
mother was concerned about his appearance and, when prompted, he
showed the bandage under his long-sleeved shirt. The man’s parents
also told my investigators they were concerned that the man had been
advised to hide the cuts on his arm.
33. On the morning of 10 April, the man was referred to a doctor after a
long chat with an officer on D wing. In the afternoon, he saw the doctor
and told staff that he was happy with the appointment. No clinical
record was made of this medical appointment, although a note was
made in the wing history file.
34. The man attended a relaxation class on 11 April. The officer that ran
the relaxation class recalled that the man attended two of them
altogether. He said that the man did not benefit from the sessions, so
halfway through the second of his sessions he left the course. The
relaxation classes are referred to in the record of an ACCT review that
took place on the same day. The man said that he felt more confident
to approach staff when he felt depressed. Another officer was helping
the man to secure employment in the prison.
35. On 12 April, an officer on D wing was doing his lunchtime checks when
he discovered the man in his cell. He appeared very low in mood. The
officer took him to the wing office and spoke to him. The man told the
officer that he felt like he was having a nervous breakdown. Following
this conversation, the officer requested that a doctor should review the
man’s medication. No note is made of the man being seen by a doctor
following this referral.
36. The man slowly began to adjust to life on D wing. On 16 April, he is
noted as having had his hair cut and being out on association. He
appeared to be in “in good spirits”. He collected his medication
regularly and repeatedly told staff that he was feeling fine.
37. A review of the man’s self-harm support plan was held on 18 April.
The man told staff that he was still feeling down, although he was
enjoying working in the stores. He said he still had thoughts of self-
harm, but was coping by occupying himself in his cell. He got on well
with his cellmate and thought that talking to him helped him cope. A
further review was recommended for 26 April. All those who attended
the review agreed that the man should remain subject to the enhanced
levels of support.
38. The man spent the morning of 20 April awaiting the decision of the
court whether or not to grant him bail. The court did not grant bail and
he was recorded as being “understandably” low. He did not go to work
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the following morning because he “did not feel like it”. Later that day,
the man told an officer that he had no energy and that he wanted to be
left on his own in a dark room. Following this conversation, that officer
spoke with a senior officer and they agreed that the man’s observation
levels had to be increased to one observation per hour.
39. The man was admitted to the healthcare centre on 21 April 2006. As
he was leaving his cell on D wing, his cellmate warned staff that the
man was low in mood. This was noted in his ACCT document.
40. An agency nurse completed the man’s healthcare admission
assessment. The record of this assessment does not include his past
medical history, the medication that he was taking at the time of his
admission or any medical observations (for example, blood pressure).
The admission form simply shows that he was being admitted to the
healthcare centre because he was “low in mood”.
41. Bedford’s healthcare centre has ten single cells, one gated cell for
prisoners who need constant observation, and one cell with three beds,
known by staff as the dormitory cell. The man was located in the
dormitory cell. When he arrived on healthcare, he was sharing it with
two other prisoners. One was interviewed by my investigators but
could not remember the man at all. He was only in the cell with the
man for the first night. The second prisoner shared the dormitory cell
with the man for nine days.
42. The man’s ACCT document was transferred with him at the same time
to the healthcare centre. There is no time lapse in the entries which
continued to be made approximately every hour. This was in line with
the agreed observation level from the last case review. The man was
recorded as reading his newspapers or talking to his cellmate for a lot
of his first evening in healthcare.
43. The following night, staff noted that the man and his cellmate sang
Elvis songs together. The man was considered as “much brighter and
in good humour”. However, the next day he complained to staff of
feeling depressed again.
44. The officer who ran the relaxation class told my investigators that he
would go and speak to the prisoners in the healthcare centre once or
twice a day, as a matter of routine, because his office was near there.
He recorded visiting the man in the healthcare centre on 24 April. He
told the officer that he continued to have fleeting thoughts of self-harm,
although no more than when he was first transferred to the healthcare
centre. The man was hopeful that he would be released on 26 April.
Despite this, he still felt despair and hopelessness which the officer
noted as “normal for depression”.
45. All prisoners who go to court must pass through the prison’s reception
area. The man’s ACCT file accompanied him to reception on 26 April.
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A note was made by an officer in reception that the man was very tired.
He told staff that he was “not getting any sleep due to his cellmate”.
This is the first record in his paperwork of this complaint.
46. The man was not granted bail on 26 April. He returned to the prison’s
healthcare centre, awaiting a further court appearance scheduled for 5
May. No note was made in his ACCT file until the morning of 27 April
when he appeared to be in a “good mood”. The man told another
officer that he had slept for most of 27 April because he had not got
much sleep the previous night.
47. The man saw a psychiatrist on 28 April. He told the psychiatrist that
his medication was not working and that he was still anxious.
Following the meeting, the psychiatrist wrote:
“No feeling. Just going through every minute/every hour.
Intermittent/fleeting suicidal thoughts. Manages them without any self-
harm.”
During this interview, the man denied that he was having any “current”
or active thoughts of suicide or self-harm.
48. The man’s suicide prevention case review was due to take place on 26
April. He was not able to attend the review because he was in court.
The duty governor drew staff’s attention to this after a standard audit
check of suicide prevention documentation. An officer and psychiatric
nurse undertook the man’s case review two days later. It was agreed
that his level of risk remained low, but the observations should remain
hourly. The man denied having suicidal thoughts during this meeting.
No mention was made of his cellmate, lack of sleep or medication in
the record of the case review. Despite this, the man requested that a
move from the dormitory, “as fellow inmate’s annoying him”.
49. The man spent the next day (29 April) in “very good spirits” according
to his ACCT file. He had a good visit and was seen talking to a
prisoner whom he had known for a number of years before coming into
prison. On 29 April, it was recorded that he was, “getting annoyed.
Wants to be in single cell.”
50. During the exercise period on 30 April, the man asked an officer about
the opportunity to work as an orderly in the healthcare centre. The
officer discussed this with nurses who agreed that the job would be
“beneficial and therapeutic”. The officer then spoke to the man when
he returned to the dormitory cell a couple of hours later. The officer
recorded him as being “more upbeat and positive than of late”. Just
one hour later, a healthcare assistant made the following entry in his
ACCT file:
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“Feeling low in mood owing to pad mate attempts to self harm. I spoke
with the man at length and is hoping for permission to relocate him.
Oscar 1 informed.”
51. The senior officer who wrote the man’s ACCT CAREMAP was again
the orderly officer for the evening shift on 30 April. During interview,
the senior officer described the shift as “a really, really busy evening”.
He had supervised the transfer of a volatile prisoner, who regularly self-
harmed, to the gated cell in the healthcare centre. It was during this
difficult transfer that the senior officer got a call from the healthcare
centre. He was told that a noose had been discovered in the dormitory
cell. Healthcare staff wanted to discuss what action could be taken.
The senior officer ensured that the prisoner who was being transferred
had settled and that the appropriate paperwork was in place. He then
asked healthcare staff about the situation in the dormitory cell.
52. The senior officer was told by nurses that the man’s cellmate had made
two nooses during the course of the day. The cellmate talked to the
man about his own thoughts of suicide. Nurses briefed the senior
officer that the man had told them he was finding it difficult share a cell
when his cellmate was talking about killing himself. When the senior
officer asked the nurses what action they recommended, he was told
that the man and his cellmate should be split up. There was a single
cell available and the nurses recommended that the man be located
there. As orderly officer in charge of the operational matters of the
prison during a shift, it was ultimately the senior officer’s decision
whether to move a prisoner. He considered the information that the
nurses had given him and agreed to their recommendation. He did not
look at the suicide prevention documentation for the man or for his
cellmate that was available in the healthcare office. He asked the
nurse to make a note of the transfer in the man’s ACCT file.
53. The senior officer entered the dormitory cell to speak to the man. He
noticed that he had already packed up his belongings. He told him that
he was going to move to a single cell. They discussed the fact that this
would mean he could get more sleep before his first day as health care
orderly the next morning. The man moved to cell 7 in the healthcare
centre. During interview, the senior officer said that he considered
increasing the man’s observation level but did not think it would be
necessary. He did not record this decision and personally made no
entry in the man’s ACCT document.
54. The health care assistant for the evening shift checked the man at
6.50pm and recorded that he was “settled”. Prisoners in healthcare
have access to small portable black and white televisions. He was
given hot water and a television at 7.10pm. The healthcare assistant
noted that the man was watching his television at 8.00pm and again
that he appeared to be “settled”.
15
55. The night shift for healthcare at Bedford are made up of one healthcare
assistant and one qualified nurse, who start their shift at around
8.30pm. The healthcare assistant described the handover from the
previous shift as being “a verbal briefing”. The evening staff discuss
each prisoner, any significant issues and how their day has been. The
healthcare assistant told my investigators that a written record is also
made in the medical records. Healthcare staff will refer to this during
their shift if there is anything not made clear during the handover.
56. On 30 April, the healthcare assistant recalled that, during handover,
staff mentioned that the man had been transferred to a single cell. The
reason that she cited for the move was because of his “awkward,
upsetting, infuriating cell mate”. She went on to describe the cellmate
as someone who regularly self-harmed using broken glass or broken
forks. She said that the cellmate had handed in “two or three nooses”
in the week before. The healthcare assistant said that, in her opinion,
the nurse and healthcare assistant on the evening shift had moved the
man to a single cell, “with the best of intentions … giving this guy some
space and peace and quiet away from [his cellmate].”
57. Following her handover, the healthcare assistant’s routine is to walk
around the healthcare centre to each of the cells and gives the
prisoners hot water for a cup of tea. When she got to the man’s cell
that night, she stopped to have a brief chat with him. During interview,
she recalled that he “looked awful, looked dreadful”. She described
him as “always well kept, clean shaven, tidy”. That night she noticed
that he had not bothered to shave for a couple of days and said that
“he just looked really rough”. When the healthcare assistant asked the
man what was wrong, he said that he had had a “rotten day”. The
healthcare assistant asked him if he would like to speak to a Listener or
to discuss his problems with her. He said that he would like to speak to
her. They had spoken at length on a couple of occasions and she said
that they enjoyed a “good rapport”. She explained that she had a
couple of jobs to do first, but that she would come back to speak with
him about ten minutes later.
58. The healthcare assistant went to check with the nurse that she could
spend some time with the man, because the nurse was running
healthcare that night. The nurse agreed that the healthcare assistant
should talk to the man. During her medication round, the nurse had
noticed that the man was lying on his bed writing. She did not speak
with him at the time, but had recorded her observation in his ACCT file.
The healthcare assistant finished off her water round, wrote some
observations in the open ACCT logs and then returned to the man’s
cell to speak with him.
59. During a night shift, all prisoners are locked in their cell. Only the
orderly officer can routinely open a prisoner’s cell. Healthcare staff
have a sealed pouch with an emergency key that they may use in
urgent situations to enter a prisoner’s cell. They have been advised to
16
use this key only in the presence of the orderly officer. The healthcare
assistant spoke to the man through the open observation panel on his
cell door.
60. They talked for nearly half an hour. The healthcare assistant said that
the man was pleased to be away from his cellmate, but that this was
not a “major concern” for him during their discussion. Instead, he told
her that he was concerned that he was going to spend ten to fifteen
years in prison. She reminded him of legal advice which suggested
that he was likely to receive a shorter sentence, but she told my
investigators that nothing she said would reassure him. The man told
the healthcare assistant that he was sorry for having hurt his family
through his drinking. He said he did not think he could ever give up
drinking completely and that he still craved it. She discussed his
anxiety and asked about his medication. Between the two of them,
they wrote a list of things that the man could do to make himself feel
better, including getting his medication reviewed and building bridges
with his wife. The healthcare assistant said that she would write the
detail of this conversation in the man’s medical record. She said that
she would request an urgent review with the mental health team to stop
him from slipping further into depression.
61. When the healthcare assistant left the man, she had convinced him to
have his cup of tea and a cigarette on his bed to calm himself down.
He agreed to try to calm down by doing some breathing exercises. As
she was leaving his cell door, he said to the healthcare assistant, “Do
you know what I have done in the past?” She replied that she did not,
because she had not had the opportunity to read his notes in any
detail. During interview, the healthcare assistant told my investigators
that, in hindsight, the man may have been referring to his previous
suicide attempts. After his death, she had reflected that he might have
been trying to warn her that he was contemplating taking his own life.
At the time, she thought he might have been referring to previous
offences. The man thanked her for everything she had done for him
and she left him at around 10.00pm.
62. After their lengthy conversation, the healthcare assistant spoke to the
nurse about her concerns for the man. She said that she did not think
that he was going to harm himself. She was concerned that they would
have a long night with him being up and out of bed and feeling anxious.
She suggested that the number of checks made on him during the
night should be increased from one an hour to “at least one every half
an hour … just to keep an eye on the guy.”
63. The healthcare assistant said that changing a prisoner’s level of
observations is usually done following a formal review of the prisoner’s
risk factors. During a night shift, there are not enough people to
conduct a formal review and changing someone’s level of observations
is more a matter of “initiative”. She explained that the night orderly
officer would be told of such a change. In this case, the night orderly
17
officer was on his way to healthcare to access the emergency
medication cupboard on the lower level for another prisoner’s
medication. As part of his duties, at the beginning of a shift the night
orderly officer visits the healthcare centre to check each of the
prisoners and the quality of the ACCT documents. The healthcare
assistant did not specifically tell the night orderly officer that she had
increased the man’s observation levels because she knew that he
would be made aware of the change on his imminent visit to
healthcare.
64. In line with the agreed increased observations, the healthcare assistant
checked the man at 10.30pm and noted that he was asleep under his
bed sheets. She said that she was relieved to see him like that,
because she thought it meant that he was “okay”. The staff toilet on
the healthcare wing is just adjacent to the man’s cell. The healthcare
assistant looked in at him again as she was on her way to the toilet at
around 10.40pm. He was still in his bed at that time.
65. At 11.00pm, the healthcare assistant went to check the prisoners on
her half hourly round. She went to the man’s cell first because it was
located at the far end of the healthcare centre. To record the check,
she carried a small device to plug into an electronic socket (a process
called ‘pegging’). As she pegged his cell, she turned to her left. She
could see directly into the cell through the open observation panel.
The healthcare assistant saw the man hanging from the window.
66. Just at that moment, the nurse, the orderly officer and an officer who
was assisting the orderly officer with his duties during his night shift
arrived back on the landing from the emergency medication cupboard
on the lower floor of the healthcare centre. They were standing
together outside the staff office, about ten metres away from the man’s
cell. The healthcare assistant shouted to them that the man was
hanging in his cell. The orderly officer and the officer assisting him
immediately ran to the cell. The orderly officer unlocked and opened
the door. The orderly officer supported the man’s weight, the officer
assisting him used an anti-ligature knife to cut the man down. (All
officers at Bedford carry an anti-ligature knife in a pouch on their belts.)
The two officers took the man’s weight and gently laid him on the floor.
The nurse instructed the healthcare assistant to go to the staff office
and fetch the emergency bag. The orderly office took the ligature from
the man’s neck and tried, unsuccessfully, to find a pulse. He asked the
nurse to try and find a pulse, but she could not. The orderly officer
used a torch that he carried with him to check the man’s eyes. He
described them as being “fixed”. Although he had no vital signs of life,
staff agreed to commence cardiopulmonary resuscitation (CPR).
67. The healthcare staff were standing at the door and the officers
commenced CPR. The officer who was assisting the orderly officer
requested a resusi-aid, a plastic device which prevents infection
through any possible bodily fluid exchange during resuscitation. Staff
18
do not carry these as a matter of course and one was not available in
the emergency response bag. The officer commenced mouth-to-mouth
with no protection for himself or for the man. The orderly officer was
performing chest compressions.
68. While performing chest compressions, the orderly officer radioed for
assistance. In his radio request, he asked for an emergency
ambulance and for another officer to come to the healthcare centre
from D wing, where he was carrying out his night shift, immediately.
The orderly officer knew that staff performing CPR would become tired
and it was his priority to get as many people to help as he could. At the
time, the door between D wing and the healthcare centre was kept
open. This meant that the officer from D wing could move freely to get
to the emergency and assist the orderly officer. When the D wing
officer arrived, he took over mouth-to-mouth. By this time, the nurse
had located a mask in the emergency bag.
69. The orderly officer left the cell and the officer assisting him took over
chest compressions. He made his way to the gate so that he could let
the ambulance through to the healthcare centre. On his way to the
gate, the orderly officer had gone to A and B wings, larger wings which
have no locked gates between them. He asked that someone go and
relieve the D wing officer because he needed to return to the wing
where he was the only officer on duty.
70. In the meantime, the nurse had taken over mouth-to-mouth. An officer
arrived from A wing with instruction to take over from the D wing officer.
The healthcare assistant was awaiting further instruction from the
man’s cell, but also continued checking on other prisoners in the
healthcare centre.
71. The orderly officer met the first ambulance five minutes after the
emergency call. He took the paramedics to the healthcare centre. He
then went back to the gate to meet a second ambulance. The A wing
officer asked the officer performing chest compressions to get a piece
of paper and write down the names of all those who had entered the
man’s cell. The officer understood that he was given this job to take
him away from the emergency and keep him busy. It was the first time
that he had come across such an emergency, and he said he was
upset by it. The paramedics took over the CPR. They administered
medication and put a tube down the man’s throat. At that point, the
staff left the man’s cell and went to the staff office.
72. Paramedics attempted to resuscitate the man in his cell. For the best
chance of survival, they decided to transport him to the local hospital
only five minutes away. The A wing officer was asked by the orderly
officer to escort the man to the hospital. An emergency response team
(known as a ‘crash’ team) was waiting at the hospital when the
ambulance arrived at 11.50pm. Emergency resuscitation attempts
19
were continued, but these were unsuccessful and the man was
pronounced dead at 00.03am on 1 May 2006.
73. The A wing officer, who had escorted the man to the hospital, rang the
prison from the hospital to notify them of the his death. He waited until
the police attended the hospital and handed them an item of the man’s
personal property. He returned to the prison at around 12.45am.
Staff Support
74. All of the staff, apart from the officer assisting the orderly officer,
continued to work the rest of their shift. That officer was given the
opportunity to go home. Instead, he elected to go and sit with the D
wing officer in the wing office. He said that this was helpful for both of
them, and meant they could discuss what had happened with each
other. He did not want to go home to a house where his family would
be sleeping.
75. All staff involved in the incident attended the hot debrief at the end of
their night shift, at about 8.00am. (A hot debrief is an opportunity for
staff to discuss the details of what has happened and share any
immediate concerns.) As there were no administrative support staff
available to minute the meeting, the Governor recorded the hot debrief
on cassette tape.
76. A critical debrief was held on 16 May 2006. This lengthier session
encouraged staff to analyse what had happened and to share any
concerns. All staff interviewed by my investigators at Bedford felt well
supported by the prison. One member of staff expressed concern that
the hot debrief was tape recorded as he felt that staff may have been
inhibited by the tape machine.
77. At the time that my investigators attended the prison, the Governor had
already begun to address shortcomings he had identified as part of the
debriefing process. I commend this prompt action. I am also pleased
to note that there has been a marked improvement in the staff support
available at Bedford since a previous investigation mounted by this
office.
Family contact
78. The man had listed his parents as his next of kin. His family were a
constant source of support throughout his time in prison. Their
frequent visits are well-recorded as lifting his mood. He also
corresponded with his wife. On the night that he died, the man’s
parents were away on an overnight trip. The prison notified the local
police. The police tried to locate the man’s parents for some time.
Eventually, the police obtained an address for his brother and visited
him at lunchtime on Monday 1 May to break the sad news. The man’s
20
father then got in touch with his parents and wife to tell them what had
happened.
79. The prison’s family liaison officer and chaplain went to the man’s
parents’ house on the afternoon of 1 May. Both the family and the
man’s wife visited Bedford prison, although on separate occasions.
80. A family liaison officer from my office, arranged to meet with the man’s
parents and brother and separately with his wife. In these meetings,
the family officer, accompanied by my investigator, explained the
investigation process and asked if there were any concerns. Both
parties raised issues to be considered during the investigation.
81. It is my policy to disclose all relevant documents to relatives and
interested persons as soon as possible during an investigation if this is
their wish. The man’s parents and his wife asked for copies of all his
prison files. Both parties received all of the documents (subject to
minor redaction in line with data protection requirements).
21
ISSUES
Was the man in the safest place in the prison?
82. The man was moved to the healthcare centre on 21 April. The reason
for admission was recorded as “low in mood, see to take medication”.
His cellmate on D wing told my investigators that he did not think the
man should have been moved to the healthcare centre. He told my
investigators that the officers on D wing were ”supportive” and that he
had a good relationship with him. He was concerned that it was only
about one week after leaving D wing that he died.
83. Bedford’s Suicide Prevention Strategy was last reviewed in September
2005. The Governor and Area Manager signed off the document.
There is a section entitled ‘Location Residential Unit or Healthcare
Centre’ on page 14 of the document. This section encourages officers
to consider the degree of risk and the level of support when deciding
where to locate prisoners subject to suicide prevention procedures.
The document recognises that a prisoner who remains on the
residential unit will stay in contact with a familiar environment and
people, and that staff can support the prisoner to deal with the
demands of the normal regime. The document goes on to suggest that
a prisoner located on the healthcare centre will receive “more intensive
supportive care and safe environment”.
84. The officers who recommended that the man should be transferred to
the healthcare centre did so because they thought it would enhance his
care. According to the suicide prevention strategy, he would receive
more support and the healthcare centre would provide a “sanctuary
from the normal regime”. The man had received increasing contact
with a psychiatric nurse leading up to the transfer from the residential
unit.
The Governor should review the Suicide Prevention Strategy to
emphasise that each prisoner must be assessed individually as to
whether a transfer to the healthcare centre is in their best
interests.
85. The ratio of staff to prisoners is indeed higher on the healthcare centre.
The man received individual care and attention from many of the
nurses and from the healthcare assistant on the night he died.
However, the regime in the healthcare centre was much reduced as
compared with that on ordinary location. The man spent a good deal of
his day in his cell. While on D wing he had been a Stores Orderly, a
coveted position, which meant that he could walk around the prison in
the fresh air. The man had got on well with his cellmate on D wing who
had provided him with support throughout his depressive episodes. By
contrast, the prisoner sharing the healthcare dormitory with the man
was self-harming and was described by the healthcare assistant as an
“awkward, upsetting, infuriating cell mate”. The man spent a prolonged
22
amount of time in the dormitory with this prisoner. He did not sleep
well and eventually requested a transfer to another cell.
The Governor and the Head of Healthcare should improve the
regime in healthcare to ensure that prisoners have more to
occupy their time and more time out of their cells.
86. Prison Service Orders (PSOs) provide detailed instructions on the
management of prisons. PSO 2700 relates to suicide and self-harm
prevention and instructs that:
“Two at-risk prisoners should not share a double cell. If it is not
advisable or practical to place a prisoner on an open F2052SH in a
shared cell, the reason for the allocation to a single cell should be
recorded in the F2052SH, and additional protective measures put in
place to compensate for the added risk.”
87. The presumption in PSO 2700 is that prisoners at risk should be in
shared accommodation. This is reinforced in Bedford’s own Suicide
Prevention Strategy:
“All prisoners subject to an open ACCT Plan will normally be located in
shared accommodation. If left on their own, at risk prisoners must be
seen by staff at intervals no longer than 30 minutes or as a support
plan in ACCT Plan indicates.”
The Governor should remind staff that prisoners who are subject
to ACCT procedures and are transferred to a single cell should be
subject to checks at least every 30 minutes in accordance with
HMP Bedford’s Suicide Prevention Strategy.
88. The prisoner sharing the dormitory cell was an at-risk prisoner who was
self-harming while in the cell with the man. The healthcare assistant
told my investigators that the cellmate:
“… was very awkward in the respect of he was always handing in
bits of broken glass, bits of broken fork because they have plastic
cutlery, bits of broken fork where he had perhaps been self harming
he had scratched or gouged his arms with it”.
During interview, the cellmate told my investigators that he spoke with
the man about self-harming and suicide, although his recollection was
that it was the man, and not him, who seemed the more preoccupied
with harming himself. There is no doubt that the man and his cellmate
were ‘two at-risk prisoners’ and therefore that they should not have
been sharing a double cell.
89. The day after the man was transferred to Bedford, the senior officer
completed a Case Review and CAREMAP. He identified that the man
was suffering from “feelings of isolation” and suggested that he should
23
aim to share accommodation and contact his family to reduce his risk.
Throughout his time at Bedford, the man had not been located in a cell
by himself. When the same senior officer authorised the transfer to the
single cell, he said that he checked the man’s ACCT file and there was
nothing that concerned him in the most recent entries. He told my
investigators that he took the advice of the nurses, who thought that
the cellmate was having a bad effect on the man and that it would be in
his interest to move to his own cell. During interview, the senior officer
said:
“To be honest with you, my main concern at that stage was [the
cellmate] because of the threats and his actions that he’d taken that
night. So I went back in and dealt with [the cellmate].”
90. The senior officer agreed with my investigators that he should have
formally reviewed and recorded any changes to the man’s
circumstances in his ACCT file. Instead, he spoke with him as he
walked to his new cell at the end of the healthcare centre and he
reassured him that he was much better for the transfer. The two men
spoke about him starting a job as the Healthcare Centre Orderly the
following morning. The senior officer said that when he left the man,
he “appeared to be that relieved to be on his own and have some
peace and quiet”. With this in mind, the senior officer, “did not feel that
it was needed” to increase his observations at that time. This decision
was in contravention of Bedford’s own suicide prevention policy which
states that at-risk prisoners who have been transferred from shared
accommodation “must be seen by staff at intervals no longer than 30
minutes”. The senior officer was trained in ACCT procedures one
month after he had been transferred to Bedford on promotion in
January 2006.
The Governor should remind staff that every decision affecting a
prisoner on an open ACCT must be made after checking the
prisoner’s documentation and must be recorded personally by the
member of staff responsible for making that decision.
91. According to his ACCT CAREMAP, the man was lonely in the prison
environment. He had gained support from his cellmates in the past on
C and D wings, during times of difficulty. He had spent nine days in the
dormitory cell in the healthcare centre, with less time out of his cell and
little to occupy him. At his own request, the man was moved to a
single cell, away from another troubled prisoner, because staff thought
it was in his best interests. Had he been sharing his cell on the
evening of 30 April, he may not have had the opportunity to take his
life. The senior officer should have personally recorded that he did not
think it necessary to increase the observations at the time of
transferring him to the cell.
92. The man was subject to half hourly observations at the time that he
died. The healthcare assistant and the nurse appropriately agreed to
24
increase the number of observations following the healthcare
assistant’s lengthy conversation with him. During interview, the
healthcare assistant said that she had not read his suicide prevention
documentation before their discussion. She did not read the
documentation before suggesting the increase in observations. The
healthcare assistant told my investigators that, as she concluded her
lengthy conversation with him, he said to her:
“… do you know what I have done in the past, and I said, no I haven’t
really had a chance to read your notes in depth. So he was oh right ok,
but then afterwards when I did have chance to read his notes I saw that
he had attempted to take his life on a couple of occasions before and I
think in a round about way he was trying to warn me.”
While I commend the healthcare assistant for taking time to speak with
the man at length about what was on his mind, this is a stark reminder
of the importance of staff reading a prisoner’s records in a timely
fashion and using the information to inform their care.
93. The man’s family was extremely worried about the design of his cell
when he died. They told my investigators that they were particularly
concerned by the pipes that ran under the window in his cell. They felt
that these pipes, combined with the bars on the window of the cell in
healthcare, afforded the man the opportunity to attempt suicide. I
realise that it is not possible for all risk to be eliminated. However, it is
embedded in Bedford’s suicide prevention policy that prisoners who
are deemed to be at particular risk of attempting self-harm or suicide
should be transferred to the healthcare centre. It seems sensible, then,
that cells should be assessed for ligature points and, where possible,
such points should be eliminated.
The Governor and the Head of Healthcare should assess the cells
in the healthcare centre for ligature points, taking action to reduce
these where possible.
Did the man receive effective treatment for his alcoholism?
Did this affect his mental state before he died?
94. Before entering custody, the man’s lifestyle had become chaotic
because of his severe depression and abuse of alcohol. His
alcoholism was identified at Woodhill, and when he arrived at Bedford
he was put on the alcohol detoxification programme immediately.
95. The detoxification nurse administered his alcohol detoxification
programme. In April 2006, there was only one detoxification nurse
working at Bedford due to staff illness. As Bedford is a local prison,
significant numbers of prisoners arrive who are suffering from alcohol
or drug withdrawal and the detoxification nurse’s task was unenviable.
She gave the man Librium, a drug routinely used for prisoners
withdrawing from alcohol. The detoxification course lasted nine days.
25
When questioned during interview, healthcare staff did not seem aware
that he had undergone the alcohol detoxification programme.
The Head of Healthcare and the Governor should ensure that
alcohol detoxification is delivered as part of mainstream
healthcare, rather than in isolation from other healthcare services.
96. When asked what work they had undertaken with the man, the
CARATs team recognised that resources for prisoners withdrawing
from alcohol are limited. They suggest that, regrettable as this is, it is a
national issue and not within their control.
The Governor should ensure, as far as possible, that there is a full
complement of staff to deliver the detoxification programme.
97. In June 2006, the month after the man’s death, the Department of
Health, in conjunction with the National Health Service, published a
document entitled, ‘Models of Care for alcohol misusers’, known as
MoCAM. MoCAM provides guidance as to how best to treat adults
affected by alcoholism. It suggests that there should be a central care
plan for patients which combines all the strands of their treatment in a
structured approach to their care. With the prioritisation of primary care
resources for alcohol services that this document recommends,
structured holistic care should become the norm for prisoners suffering
from alcohol withdrawal, rather than the exception. Alcohol withdrawal
is dangerous and, coupled with depression, might be crucial to the
mental balance of prisoners.
98. During his last conversation with the healthcare assistant, the man
reflected that he could never successfully give up alcohol. He said that
he had no control over his life. There can be little doubt that he did not
feel he had effectively addressed his problems with alcohol and that
this was on his mind on the evening that he died.
Was there an appropriate response when the man was discovered?
99. The man was discovered in his cell by the healthcare assistant.
Despite being in the healthcare centre, with the only nurse on duty for
the night shift present, it was prison officers who commenced and
continued Cardio-Pulmonary Resuscitation(CPR). There is a
defibrillator available in the healthcare office. Although the nurse had
experience of working in the Accident and Emergency Department of
the local hospital, she was not trained in the use of a defibrillator.
Healthcare staff should be trained in the use of a defibrillator and
there should be a member of staff who has been trained in its
usage on duty at any time.
100. I must commend the resuscitation efforts of the orderly officer and the
officer assisting him. However, I am surprised that the skilled
26
healthcare staff on duty at that time did not immediately take control of
the resuscitation efforts. I am concerned that the officer assisting the
orderly officer did not have access to a face guard to protect himself
during mouth to mouth resuscitation efforts.
Response staff should carry protective equipment, such as a
pocket mask, at all times.
101. A critical debrief was held on the morning following the man’s death. In
general, staff felt that it was useful to talk about his death at that early
stage. One member of staff suggested the fact the debrief was taped
was unhelpful. My investigators were told by the Governor that this
was not ideal, but had been unavoidable given a shortfall in
administration staff that morning. I agree that taping such a sensitive
meeting should be avoided in future and commend this for the
consideration of the Governor as a matter of housekeeping.
The Clinical Review
102. Primary Care Trusts (PCTs) are responsible for undertaking a clinical
review following all deaths of prisoners in Prison Service
establishments. When my investigator initially contacted Bedfordshire
PCT, they expressed concern that the clinical review would not be
sufficiently independent. Since April 2005, the PCT has provided and
managed healthcare services in HMP Bedford. In light of their
concerns, they appointed the clinical reviewer from a neighbouring
PCT, to conduct the review on their behalf. The man’s wife was
concerned about the independence of the clinical reviewer because the
clinical reviewer was a Prison Service employee at the time he
conducted the clinical review. The clinical review was thorough and
balanced to provide an assessment of clinical care sufficient for the
purposes of this investigation. However, I can understand that the
appointment of a Prison Service employee could be also be criticised
as being insufficiently independent. On receipt of this report, the
Bedfordshire PCT may care to seek further central advice on the
matter from the Department of Health.
103. There was a slight delay in appointing the clinical review. By the time
the appointment had been made, healthcare staff had been interviewed
by investigators from my office, the police and their own senior
management team. The Human Resources department of
Bedfordshire PCT requested that staff should not be interviewed a
further time. For this reason, the clinical reviewer did not visit the
prison or speak to staff directly. He liaised with the Head of Healthcare
at Bedford during the course of his paper-based review. He was given
full access to all records and transcripts of staff interviews previously
conducted by my investigators.
104. The clinical reviewer considered the available paperwork and makes
the following six recommendations:
27
• This report recommends that healthcare professionals are trained in
the use of an Automated External Defibrillator (AED) on an annual
basis with intermittent refreshers and that several AEDs are placed
strategically throughout the establishment.
• This report recommends that front line staff carry protective equipment
such as a pocket mask or face shield.
• This report recommends all First Responders undertake initial training
and subsequent refreshers in First Aid/CPR in accordance with
national guidance.
• It is recommended that healthcare professionals are empowered to
take charge at a medical emergency and that this is embedded in a
written framework.
• It is recommended that [improving the quality of ACCT recording and
ensuring timely reviews when a prisoner’s circumstances change
significantly] is reinforced through the Safer Custody Manager and
Head of Healthcare.
• It is recommended, from reading the Inmate Medical Record (IMR),
that policy and practices are developed to ensure greater collaborative
working and interaction between the different strands of healthcare
delivery – healthcare, mental health in-reach and detoxification. In
particular, a standard patient group directive should be followed by all
clinicians when prisoners undertake an alcohol detoxification
programme.
105. The clinical reviewer’s expert recommendations reinforce crucial areas
in the care of any prisoners, particularly those suffering from mental
health problems and alcohol dependency. I agree with all of his
recommendations and fully endorse them.
106. An independent report was commissioned by the Coroner as part of
the inquest proceedings and received in my office during the
consultation period. The report was carried out be a Consultant
Psychiatrist, who was asked to compare the treatment that the man
received in Bedford prison, compared to his treatment in the
community. The Consultant Psychiatrist concluded that:
“I would judge the management of his withdrawal from alcohol
and benzodiazepines, the recognition of his need for ongoing
treatment of his addiction, assessment of his mood n an ongoing
manner and attempts with pharmacology, i.e. anti-depressants,
to attenuate his mood to have been appropriate interventions.”
The independent report makes no recommendations.
28
107. In his analysis of the man’s clinical records, the clinical reviewer
identified the following areas of good practice:
• The interaction between the man and the healthcare assistant and
subsequent documentation in the [medical record] is to be
commended.
• The action of the officers who attended the incident is to be
commended. They exercised a clear duty of care, to the best of their
ability.
• The support mechanisms offered by HMP Bedford and the PCT to the
staff are clearly robust and to be applauded.
108. As part of the clinical review process, a colleague of the clinical
reviewer, reviewed the dosage of medication that the man was
prescribed and found it to be higher than he would expect, but within
clinical guidelines. However, he made the following recommendations:
• The most important issue is to ensure that all staff who
prescribe/issue chlordiazepoxide for alcohol detoxification are
following a robust (pre-agreed) standard operating procedure or
policy with clear dosage guidelines in response to severity of
symptoms with the possibility for regular review if the patient or staff
involved raise concerns.
• The standardised detoxification policy should encourage the
recording of any possible side effects.
The man’s family’s concerns
109. During the course of the investigation, the man’s family expressed
several concerns about his care. I have endeavoured to respond to all
of these concerns in the body of the report.
110. In addition, the man’s wife raised a concern about the manner in which
the prison dealt with her when she visited. She felt that prison staff
were dismissive of her and, just prior to the visit, she was told that ”if
there was trouble” she “would be escorted off the premises”.
111. His wife was also concerned about the return of his property as she is
his legal next of kin. She had written to the prison to notify them of this.
However, she received no response to her letter and her general
impression of the prison was that issues were “not followed up”. She
asked to whom the property had been returned and it was not until my
investigators asked the prison on her behalf that she discovered that
the property had been returned to other family members. I recognise
that it can be difficult to identify a prisoner’s next of kin. In good faith,
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the prison had returned the man’s property to his parents whom he had
identified as his next of kin upon his reception at Bedford.
112. There is a Prison Service family liaison toolkit for staff nominated as
the family liaison officer following a death in custody. The duties of a
family liaison officer are listed in the toolkit and include:
“To offer support, practical help and advice to the family (before
and after the inquest).”
The man’s parents also expressed concern that, as at December, they
had not received acknowledgment of a letter that they sent to the
prison, copied to the Governor, in October.
113. I conclude from this that the family liaison function may properly extend
beyond the few days following a prisoner’s death. Furthermore, where
there is some confusion about who is the prisoner’s next of kin, prisons
should deal with any requests for information transparently and swiftly.
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RECOMMENDATIONS
I have made nine recommendations:
The Governor should review the Suicide Prevention Strategy to
emphasise that each prisoner must be assessed individually as to
whether a transfer to the healthcare centre is in their best interests.
The Governor and the Head of Healthcare should improve the regime in
healthcare to ensure that prisoners have more to occupy their time and
more time out of their cells.
The Governor should remind staff that prisoners who are subject to
ACCT procedures and are transferred to a single cell should be subject
to checks at least every 30 minutes in accordance with HMP Bedford’s
Suicide Prevention Strategy.
The Governor should remind staff that every decision affecting a
prisoner on an open ACCT must be made after checking the prisoner’s
documentation and must be recorded personally by the member of staff
responsible for making that decision.
The Governor and the Head of Healthcare should assess the cells in the
healthcare centre for ligature points, taking action to reduce these
where possible.
The Head of Healthcare and the Governor should ensure that alcohol
detoxification is delivered as part of mainstream healthcare, rather than
in isolation from other healthcare services.
The Governor should ensure, as far as possible, that there is a full
complement of staff to deliver the detoxification programme.
Healthcare staff should be trained in the use of a defibrillator and there
should be a member of staff who has been trained in its usage on duty
at any time.
Response staff should carry protective equipment, such as a pocket
mask, at all times.
The Clinical Reviewer, makes a further six recommendations which I endorse:
This report recommends that healthcare professionals are trained in the
use of an Automated External Defibrillator (AED) on an annual basis
with intermittent refreshers and that several AEDs are placed
strategically throughout the establishment.
This report recommends that front line staff carry protective equipment
such as a pocket mask or face shield.
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This report recommends all First Responders undertake initial training
and subsequent refreshers in First Aid/CPR in accordance with national
guidance.
It is recommended that healthcare professionals are empowered to take
charge at a medical emergency and that this is embedded in a written
framework.
It is recommended that [improving the quality of ACCT recording and
ensuring timely reviews when a prisoner’s circumstances change
significantly] is reinforced through the Safer Custody Manager and Head
of Healthcare.
It is recommended, from reading the Inmate Medical Record (IMR), that
policy and practices are developed to ensure greater collaborative
working and interaction between the different strands of healthcare
delivery – healthcare; mental health in-reach and detoxification. In
particular, a standard patient group directive should be followed by all
clinicians when prisoners undertake an alcohol detoxification
programme.
The pharmacy technician, in his analysis of the man’s medication, made the
following two recommendations:
The most important issue is to ensure that all staff who prescribe/issue
chlordiazepoxide for alcohol detoxification are following a robust (pre-
agreed) standard operating procedure or policy with clear dosage
guidelines in response to severity of symptoms with the possibility for
regular review if the patient or staff involved raise concerns.
The standardised detoxification policy should encourage the recording
of any possible side effects.
Good practice
I strongly agree with the commendations of the clinical reviewer:
The interaction between the man and the healthcare assistant and
subsequent documentation in the [medical record] is to be commended.
The action of the officers who attended the incident is to be
commended. They exercised a clear duty of care, to the best of their
ability.
The support mechanisms offered by HMP Bedford and the PCT to the
staff are clearly robust and to be applauded.
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